Important Questions Answers Why this Matters:

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1 BridgeSpan Health Company: Silver HDHP 2500 RealValue Coverage Period: 01/01/ /31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington or by calling 1 (855) Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? In-network: $2,500 single / $5,000 family per calendar year. Out-of-network: $6,000 single / $12,000 family per calendar year. Doesn t apply to pediatric vision services and the following in-network services: certain preventive care. Amounts in excess of the allowed amount do not count toward the deductible. No. Yes. In-network: $6,200 single / $12,400 family* per calendar year. Out-of-network: Unlimited. *A member on family coverage will not have his or her out-of-pocket limit exceed $6,200. Premiums, balance-billed charges, and health care this plan doesn t cover. Yes. See bridgespanhealth.com/realvaluewashington or call 1 (855) for lists of in-network or out-of-network providers. No. You don t need a referral to see a specialist. Yes. Single: You must pay all the costs up to the single deductible amount before this plan begins to pay for covered services you use. Family: Members collectively must pay all the costs up to the family deductible amount before this plan begins to pay for any member s covered services. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call 1 (855) or visit us at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington. If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call 1 (855) to request a copy. 1 of 8 WWB0117SSHSAIE

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Primary care visit to 20% coinsurance 50% coinsurance treat an injury or illness none Specialist visit 20% coinsurance 50% coinsurance Other practitioner office visit 20% coinsurance 50% coinsurance Preventive care/ screening/immunization No charge 50% coinsurance none Diagnostic test (x-ray, blood work) 20% coinsurance 50% coinsurance Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance none Coverage is limited to 12 acupuncture visits / year. Coverage is limited to 10 spinal manipulations / year. 2 of 8 WWB0117SSHSAIE

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bridgespanhealth.co m/formulary/2017/ 6tierEssentialWA. If you have outpatient surgery Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider 10% coinsurance* / preferred generic retail prescription 5% coinsurance / preferred generic mail order prescription 25% coinsurance* / non-preferred generic retail prescription 20% coinsurance / non-preferred generic mail order prescription 35% coinsurance* / retail prescription 30% coinsurance / mail order prescription 50% coinsurance* / retail prescription 45% coinsurance / mail order prescription 40% coinsurance / preferred specialty drug prescription 50% coinsurance non-preferred specialty drug prescription Limitations & Exceptions No coverage for prescription drugs not on the Essential Formulary or prescription drugs from an outof-network pharmacy. Coverage is limited to a 90-day supply retail or mail order. Coverage is limited to a 30-day supply for injectable drugs, specialty drugs and self-administrable cancer chemotherapy drugs. Deductible waived for certain preventive drugs and immunizations at a participating pharmacy. No charge for FDA-approved women s contraceptives prescribed by a health care provider. Deductible waived for generic or formulary brand drugs designated as preventive for treatment of certain chronic diseases listed on the Optimum Value Medication list. The first fill is allowed at a retail pharmacy for specialty drugs. Additional fills must be provided at a specialty pharmacy. Coverage for self-administrable cancer chemotherapy drugs is 20% coinsurance. Specialty self-administrable cancer chemotherapy drugs must be purchased at a specialty pharmacy. *5% off coinsurance discount when filled at a preferred pharmacy. Facility fee (e.g., ambulatory surgery 10% coinsurance 50% coinsurance none center) Physician/surgeon fees 10% coinsurance 50% coinsurance none 3 of 8 WWB0117SSHSAIE

4 Common Medical Event If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Emergency room services 20% coinsurance none Emergency medical transportation 20% coinsurance none Urgent care 20% coinsurance 50% coinsurance none Facility fee (e.g., hospital Coverage is limited to $3,000 / day for inpatient 20% coinsurance 50% coinsurance room) non-emergency admission in out-of-network facilities. Physician/surgeon fee 20% coinsurance 50% coinsurance none Mental/Behavioral health outpatient 20% coinsurance 50% coinsurance services Mental/Behavioral 20% coinsurance 50% coinsurance Coverage is limited to $3,000 / day for inpatient health inpatient services non-emergency admission in out-of-network facilities. Substance use disorder 20% coinsurance 50% coinsurance outpatient services Substance use disorder inpatient services 20% coinsurance 50% coinsurance Prenatal and postnatal 20% coinsurance 50% coinsurance care Coverage is limited to $3,000 / day for inpatient Delivery and all non-emergency admission in out-of-network facilities. 20% coinsurance 50% coinsurance inpatient services Home health care 20% coinsurance 50% coinsurance Coverage is limited to 130 visits / year. Coverage is limited to 30 inpatient days and 25 Rehabilitation services 20% coinsurance 50% coinsurance outpatient visits / year. Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. Coverage for habilitative services is limited to 30 inpatient days and 25 outpatient visits / year. Habilitation services 20% coinsurance 50% coinsurance Coverage for neurodevelopmental therapy is limited to 25 outpatient visits / year. Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. Skilled nursing care 20% coinsurance 50% coinsurance Coverage is limited to 60 inpatient days / year. 4 of 8 WWB0117SSHSAIE

5 Common Medical Event If your child needs dental or eye care Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Durable medical equipment 20% coinsurance 50% coinsurance none Hospice service 20% coinsurance 50% coinsurance Coverage is limited to 14 respite days / lifetime. Eye exam No charge No charge Coverage is limited to insureds under the age of 19. Coverage is limited to one routine exam / year. Coverage is limited to insureds under the age of 19. Glasses No charge No charge Coverage is limited to one pair of lenses (2 lenses) and one frame / year. Dental check-up Not covered Not covered none Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Bariatric surgery Infertility treatment Routine eye care (Adult) Cosmetic surgery, except congenital anomalies Long-term care Routine foot care Dental care (Adult) Hearing aids Non-emergency care when traveling outside the U.S. Private-duty nursing Vision hardware (Adult) Weight loss programs, except as covered under preventive care Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care Termination of pregnancy 5 of 8 WWB0117SSHSAIE

6 Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside of the coverage area For more information on your rights to continue coverage, contact the plan at 1 (855) You may also contact your state insurance department at 1 (800) or Your Grievance and Appeals Rights: Contact the Washington State Office of the Insurance Commissioner at 1 (800) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 1 (855) To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8 WWB0117SSHSAIE

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays: $3,930 Patient pays: $3,610 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $2,500 Copays $0 Coinsurance $960 Limits or exclusions $150 Total $3,610 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $2,300 Patient pays: $3,100 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $2,500 Copays $0 Coinsurance $560 Limits or exclusions $40 Total $3,100 Patient pays amounts in this coverage example are based on Individual coverage. Different amounts may apply in Family coverage. Consult your plan documents for more information about your cost-sharing. 7 of 8 WWB0117SSHSAIE

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 1 (855) or visit us at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington. If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call 1 (855) to request a copy. 8 of 8 WWB0117SSHSAIE

9 BridgeSpan Health Company: Silver HDHP 2500 RealValue Coverage Period: 01/01/ /31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington-300 or by calling 1 (855) Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? In-network: $0 single / $0 family per calendar year. Out-of-network: $0 single / $0 family per calendar year. Doesn t apply to pediatric vision services and the following in-network services: certain preventive care. Amounts in excess of the allowed amount do not count toward the deductible. No. Yes. In-network: $0 single / $0 family per calendar year. Out-of-network: $0 Premiums, balance-billed charges, and health care this plan doesn t cover. Yes. See bridgespanhealth.com/realvaluewashington or call 1 (855) for lists of in-network or out-of-network providers. No. You don t need a referral to see a specialist. Yes. Single: You must pay all the costs up to the single deductible amount before this plan begins to pay for covered services you use. Family: Members collectively must pay all the costs up to the family deductible amount before this plan begins to pay for any member s covered services. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call 1 (855) or visit us at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington-300. If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call 1 (855) to request a copy. 1 of 8 WWB0117SSHTLIE

10 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Primary care visit to 0% coinsurance 0% coinsurance treat an injury or illness none Specialist visit 0% coinsurance 0% coinsurance Other practitioner office visit 0% coinsurance 0% coinsurance Preventive care/ screening/immunization No charge 0% coinsurance none Diagnostic test (x-ray, blood work) 0% coinsurance 0% coinsurance Imaging (CT/PET scans, MRIs) 0% coinsurance 0% coinsurance none Coverage is limited to 12 acupuncture visits / year. Coverage is limited to 10 spinal manipulations / year. 2 of 8 WWB0117SSHTLIE

11 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bridgespanhealth.co m/formulary/2017/ 6tierEssentialWA. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider 0% coinsurance / preferred generic retail prescription 0% coinsurance / preferred generic mail order prescription 0% coinsurance / non-preferred generic retail prescription 0% coinsurance / non-preferred generic mail order prescription 0% coinsurance / retail prescription 0% coinsurance / mail order prescription 0% coinsurance / retail prescription 0% coinsurance / mail order prescription 0% coinsurance / preferred specialty drug prescription 0% coinsurance non-preferred specialty drug prescription Limitations & Exceptions No coverage for prescription drugs not on the Essential Formulary or prescription drugs from an outof-network pharmacy. Coverage is limited to a 90-day supply retail or mail order. Coverage is limited to a 30-day supply for injectable drugs, specialty drugs and self-administrable cancer chemotherapy drugs. Deductible waived for certain preventive drugs and immunizations at a participating pharmacy. No charge for FDA-approved women s contraceptives prescribed by a health care provider. Deductible waived for generic or formulary brand drugs designated as preventive for treatment of certain chronic diseases listed on the Optimum Value Medication list. The first fill is allowed at a retail pharmacy for specialty drugs. Additional fills must be provided at a specialty pharmacy. Coverage for self-administrable cancer chemotherapy drugs is 0% coinsurance. Specialty self-administrable cancer chemotherapy drugs must be purchased at a specialty pharmacy. Facility fee (e.g., ambulatory surgery 0% coinsurance 0% coinsurance none center) Physician/surgeon fees 0% coinsurance 0% coinsurance none Emergency room services 0% coinsurance none Emergency medical transportation 0% coinsurance none Urgent care 0% coinsurance 0% coinsurance none Facility fee (e.g., hospital room) 0% coinsurance 0% coinsurance none 3 of 8 WWB0117SSHTLIE

12 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Physician/surgeon fee 0% coinsurance 0% coinsurance none Mental/Behavioral health outpatient 0% coinsurance 0% coinsurance services Mental/Behavioral 0% coinsurance 0% coinsurance health inpatient services none Substance use disorder outpatient services 0% coinsurance 0% coinsurance Substance use disorder inpatient services 0% coinsurance 0% coinsurance Prenatal and postnatal care 0% coinsurance 0% coinsurance Delivery and all inpatient services 0% coinsurance 0% coinsurance none Home health care 0% coinsurance 0% coinsurance Coverage is limited to 130 visits / year. Rehabilitation services 0% coinsurance 0% coinsurance Coverage is limited to 30 inpatient days and 25 outpatient visits / year. Coverage for habilitative services is limited to 30 Habilitation services 0% coinsurance 0% coinsurance inpatient days and 25 outpatient visits / year. Coverage for neurodevelopmental therapy is limited to 25 outpatient visits / year. Skilled nursing care 0% coinsurance 0% coinsurance Coverage is limited to 60 inpatient days / year. Durable medical equipment 0% coinsurance 0% coinsurance none Hospice service 0% coinsurance 0% coinsurance Coverage is limited to 14 respite days / lifetime. Eye exam No charge No charge Coverage is limited to insureds under the age of 19. Coverage is limited to one routine exam / year. Coverage is limited to insureds under the age of 19. Glasses No charge No charge Coverage is limited to one pair of lenses (2 lenses) and one frame / year. Dental check-up Not covered Not covered none 4 of 8 WWB0117SSHTLIE

13 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Bariatric surgery Infertility treatment Routine eye care (Adult) Cosmetic surgery, except congenital anomalies Long-term care Routine foot care Dental care (Adult) Hearing aids Non-emergency care when traveling outside the U.S. Private-duty nursing Vision hardware (Adult) Weight loss programs, except as covered under preventive care Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care Termination of pregnancy Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside of the coverage area For more information on your rights to continue coverage, contact the plan at 1 (855) You may also contact your state insurance department at 1 (800) or Your Grievance and Appeals Rights: Contact the Washington State Office of the Insurance Commissioner at 1 (800) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. 5 of 8 WWB0117SSHTLIE

14 Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 1 (855) To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8 WWB0117SSHTLIE

15 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays: $7,390 Patient pays: $150 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $0 Coinsurance $0 Limits or exclusions $150 Total $150 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $5,360 Patient pays: $40 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $0 Coinsurance $0 Limits or exclusions $40 Total $40 Patient pays amounts in this coverage example are based on Individual coverage. Different amounts may apply in Family coverage. Consult your plan documents for more information about your cost-sharing. 7 of 8 WWB0117SSHTLIE

16 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 1 (855) or visit us at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington-300. If you aren t clear about any of the underlined terms used in this form, see the Glossary. 8 of 8 You can view the Glossary at or call 1 (855) to request a copy. WWB0117SSHTLIE

17 BridgeSpan Health Company: Silver HDHP 2500 RealValue Coverage Period: 01/01/ /31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington or by calling 1 (855) Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket limit on my expenses? What is not included in the out-of-pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? In-network: $2,500 single / $5,000 family per calendar year. Out-of-network: $6,000 single / $12,000 family per calendar year. Doesn t apply to pediatric vision services and the following in-network services: certain preventive care. Amounts in excess of the allowed amount do not count toward the deductible. No. Yes. In-network: $6,200 single / $12,400 family* per calendar year. Out-of-network: Unlimited. *A member on family coverage will not have his or her out-of-pocket limit exceed $6,200. Premiums, balance-billed charges, and health care this plan doesn t cover. Yes. See bridgespanhealth.com/realvaluewashington or call 1 (855) for lists of in-network or out-of-network providers. No. You don t need a referral to see a specialist. Yes. Single: You must pay all the costs up to the single deductible amount before this plan begins to pay for covered services you use. Family: Members collectively must pay all the costs up to the family deductible amount before this plan begins to pay for any member s covered services. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call 1 (855) or visit us at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington. If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call 1 (855) to request a copy. 1 of 8 WWB0117SSHTHIE

18 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Primary care visit to 20% coinsurance 50% coinsurance treat an injury or illness none Specialist visit 20% coinsurance 50% coinsurance Other practitioner office visit 20% coinsurance 50% coinsurance Preventive care/ screening/immunization No charge 50% coinsurance none Diagnostic test (x-ray, blood work) 20% coinsurance 50% coinsurance Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance none Coverage is limited to 12 acupuncture visits / year. Coverage is limited to 10 spinal manipulations / year. 2 of 8 WWB0117SSHTHIE

19 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bridgespanhealth.co m/formulary/2017/ 6tierEssentialWA. If you have outpatient surgery Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider 10% coinsurance* / preferred generic retail prescription 5% coinsurance / preferred generic mail order prescription 25% coinsurance* / non-preferred generic retail prescription 20% coinsurance / non-preferred generic mail order prescription 35% coinsurance* / retail prescription 30% coinsurance / mail order prescription 50% coinsurance* / retail prescription 45% coinsurance / mail order prescription 40% coinsurance / preferred specialty drug prescription 50% coinsurance non-preferred specialty drug prescription Limitations & Exceptions No coverage for prescription drugs not on the Essential Formulary or prescription drugs from an outof-network pharmacy. Coverage is limited to a 90-day supply retail or mail order. Coverage is limited to a 30-day supply for injectable drugs, specialty drugs and self-administrable cancer chemotherapy drugs. Deductible waived for certain preventive drugs and immunizations at a participating pharmacy. No charge for FDA-approved women s contraceptives prescribed by a health care provider. Deductible waived for generic or formulary brand drugs designated as preventive for treatment of certain chronic diseases listed on the Optimum Value Medication list. The first fill is allowed at a retail pharmacy for specialty drugs. Additional fills must be provided at a specialty pharmacy. Coverage for self-administrable cancer chemotherapy drugs is 20% coinsurance. Specialty self-administrable cancer chemotherapy drugs must be purchased at a specialty pharmacy. *5% off coinsurance discount when filled at a preferred pharmacy. Facility fee (e.g., ambulatory surgery 10% coinsurance 50% coinsurance none center) Physician/surgeon fees 10% coinsurance 50% coinsurance none 3 of 8 WWB0117SSHTHIE

20 Common Medical Event If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Emergency room services 20% coinsurance none Emergency medical transportation 20% coinsurance none Urgent care 20% coinsurance 50% coinsurance none Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. This limit does not apply to services from an Indian health care provider. Physician/surgeon fee 20% coinsurance 50% coinsurance none Mental/Behavioral health outpatient 20% coinsurance 50% coinsurance services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. This limit does not apply to services from an Indian health care provider. Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. This limit does not apply to services from an Indian health care provider. 4 of 8 WWB0117SSHTHIE

21 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-of- Network Provider Limitations & Exceptions Home health care 20% coinsurance 50% coinsurance Coverage is limited to 130 visits / year. Rehabilitation services 20% coinsurance 50% coinsurance Coverage is limited to 30 inpatient days and 25 outpatient visits / year. Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. This limit does not apply to services from an Indian health care provider. Habilitation services 20% coinsurance 50% coinsurance Coverage for habilitative services is limited to 30 inpatient days and 25 outpatient visits / year. Coverage for neurodevelopmental therapy is limited to 25 outpatient visits / year. Coverage is limited to $3,000 / day for inpatient non-emergency admission in out-of-network facilities. This limit does not apply to services from an Indian health care provider. Skilled nursing care 20% coinsurance 50% coinsurance Coverage is limited to 60 inpatient days / year. Durable medical equipment 20% coinsurance 50% coinsurance none Hospice service 20% coinsurance 50% coinsurance Coverage is limited to 14 respite days / lifetime. Eye exam No charge No charge Coverage is limited to insureds under the age of 19. Coverage is limited to one routine exam / year. Coverage is limited to insureds under the age of 19. Glasses No charge No charge Coverage is limited to one pair of lenses (2 lenses) and one frame / year. Dental check-up Not covered Not covered none Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Bariatric surgery Infertility treatment Routine eye care (Adult) Cosmetic surgery, except congenital anomalies Long-term care Routine foot care Dental care (Adult) Non-emergency care when traveling outside Vision hardware (Adult) 5 of 8 WWB0117SSHTHIE

22 Hearing aids the U.S. Private-duty nursing Weight loss programs, except as covered under preventive care Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care Termination of pregnancy Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside of the coverage area For more information on your rights to continue coverage, contact the plan at 1 (855) You may also contact your state insurance department at 1 (800) or Your Grievance and Appeals Rights: Contact the Washington State Office of the Insurance Commissioner at 1 (800) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 1 (855) of 8 WWB0117SSHTHIE

23 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 7 of 8 WWB0117SSHTHIE

24 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays: $3,930 Patient pays: $3,610 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $2,500 Copays $0 Coinsurance $960 Limits or exclusions $150 Total $3,610 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $2,300 Patient pays: $3,100 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $2,500 Copays $0 Coinsurance $560 Limits or exclusions $40 Total $3,100 Patient pays amounts in this coverage example are based on Individual coverage. Different amounts may apply in Family coverage. Consult your plan documents for more information about your cost-sharing. 8 of 8 WWB0117SSHTHIE

25 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call 1 (855) or visit us at bridgespanhealth.com/policy/2017/wa/silverhdhp2500realvaluewashington. If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call 1 (855) to request a copy. 9 of 8 WWB0117SSHTHIE